D. Ballance Assignment #2 1. Assignment #2: Ethical Decision-Making Exercise APSY 603. August 9, Dianne Ballance

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1 D. Ballance Assignment #2 1 Assignment #2: Ethical Decision-Making Exercise APSY 603 August 9, 2011 Dianne Ballance

2 D. Ballance Assignment #2 2 Vignette You have been asked to counsel an 11-year-old aboriginal youth who is withdrawn in school and spends a lot of time alone. He is accompanied by his grandmother who says that they need each other very much because her husband has died recently. The youth describes feeling alone, remembering times when he has been abandoned, and hearing voices singing and the voice of an old man speaking to him in the tribal dialect. The grandmother is not eating or sleeping well and she thinks a lot about traumatic events experienced in residential school. You are uncomfortable about counselling without first obtaining a psychiatric assessment to evaluate what may be psychotic symptoms. A psychiatric assessment would require a trip some 100 miles away to a large urban centre. The Ethical Decision-Making model of the Canadian Code of Ethics for Psychologists (Sinclair & Pettifor, 2001) includes a ten step process that identifies issues that will be applied to the vignette to assist in thinking through the situation and deciding upon an ethical response to the grandmother and the youth. The format used to apply the ethical decision-making process follows the model presented in the Companion Manual to the Canadian Code of Ethics for Psychologists, Third Edition (Sinclair & Pettifor, 2001). My ethical decision making process reflects the process of recognizing the issues around consultation and referral for psychiatric services, identifying immediate concerns/issues, and exactly what role or support I may provide to the youth/grandmother that is within my areas of competence. How do you respond to the grandmother and the youth? This situation requires careful thought and consideration given its complexity and different factors impacting the situation. Services for the youth have been requested, although it appears that the grandmother could also benefit from some type of support. Primary concerns involve seriousness of symptomology (and risk), cultural influences, immediate needs, and my areas of competence and greatest responsibilities. Critical ethical issues are evident, and require working through the decision-making model to arrive at the best possible course of action. My response to the grandmother and the youth will reflect my decision after working through the process and highlight getting them the best possible service that addresses their needs.

3 D. Ballance Assignment #2 3 Communication would clearly describe my own limitations, options, risks and benefits, alternatives, my commitment to securing appropriate support, and what I am able to offer in the way of services. Step 1. Identification of the Individuals and Groups Potentially Affected by the Decision The primary individuals that I see being affected by my decision are the youth and his grandmother. There appears to be a strong relationship between the youth and his grandmother and any mental health issues or counseling will likely have a significant effect on both individuals. Additionally, other individuals that may potentially be affected include other family members, school staff, classmates or friends, and aboriginal community members as they are connected on different levels to their situation. Culturally, there may be different views or support for the youth and his grandmother regarding my decision to provide referrals or services. I would also be concerned about my role in providing services within my areas of competence and resulting credibility. Step 2. Identification of Ethically Relevant Issues and Practices, Including the Interests, Rights, and Any Relevant Characteristics of the Individuals and Groups Involved and the System or Circumstances in Which the Ethical Problem Arose Principle/Value My Thoughts PRINCIPLE I: RESPECT FOR THE DIGNITY OF PERSONS Value: General Respect I.1 Demonstrate appropriate respect for the knowledge, insight, experience, and areas of expertise of others. I.3 Strive to use language that conveys respect for the dignity of persons as much as possible in all written and oral communication. Respect and consider the insights and knowledge within the family/culture and how they process grief and address mental health issues. I also need to consider the need for professional expertise in psychiatric assessment, and aboriginal knowledge/services. Recognize that the youth and his grandmother may speak English as a second language and that there may be cultural differences between

4 D. Ballance Assignment #2 4 Value: Informed Consent I. 16 Seek as full and active participation as possible from others in decisions that affect them, respecting and integrating as much as possible their opinions and wishes. I. 18 Respect the expressed wishes of persons to involve others (e.g. family members, community members) in their decision making regarding informed consent. I. 19 Obtain informed consent from all independent and partially dependent persons for any psychological services provided to them except in circumstances of urgent need (e.g., disaster or other crisis). English and their native language that require sensitive and thoughtful communication efforts. Involve the grandmother and the youth (to the greatest extent possible) in the decision to refer for psychiatric assessment. Recognize that there may be persons within their native community that provide support and guidance in assisting families that the youth/grandmother may want to consult with regarding my recommendation for psychiatric assessment. Determine/confirm who is the legal guardian of the youth (is it the grandmother or another family member) and take steps to obtain consent for services to address immediate health concerns or referrals. Determine if there is any immediate crisis. I. 24 Ensure, in the process of obtaining informed consent, that at least the following points are understood: purpose and nature of the activity, mutual responsibilities, confidentiality protection and limitations, likely benefits and risks, alternatives, the likely consequences of non-action, the option to refuse or withdraw at any time, without prejudice, over what period of time consent applies, and how to rescind consent if desired. Related to this value is a need to ensure that there is clear communication regarding my own competence and explain my reasoning for suggesting a referral for psychiatric assessment (risks/benefits/etc.). Value: Protections for Vulnerable Persons Values Statement: The nature of the contract with society demands that the psychologists greatest responsibility be to those persons in the most vulnerable position. The most vulnerable person in this case is the youth as he has experienced a loss, is experiencing potentially serious mental health symptoms, is a minor, and part of a minority culture. My greatest responsibility is in providing immediate short-term care, assessing imminent harm, and assistance in securing

5 D. Ballance Assignment #2 5 PRINCIPLE II: RESPONSIBLE CARING Value: General Caring appropriate care/services (ensuring his right to treatment is dealt with whatever decision is made). II. 1 Protect and promote the welfare of clients, research participants, employees, supervisees, students, trainees, colleagues, and others. Values Statement: Psychologists recognize that as vulnerabilities increase or as power to control one s own life decreases, psychologists have an increasing responsibility to protect the well-being of the individual, family, group, or community involved. I am concerned about promoting the welfare of the youth and his grandmother and determining the best possible choice of action for referrals and services, and determining if there is anything I need/can do for immediate concerns The youth is the most vulnerable person in this situation, and my course of action needs to promote his well-being. I think it would also be ethical to help the grandmother find/secure counselling support to help her with her own issues (grief and traumatic past). Value: Competence and Self-Knowledge II.6 Offer or carry out (without supervision) only those activities for which they have established their competence to carry them out to the benefit of others. II.8 Take immediate steps to obtain consultation or to refer a client to a colleague or other professional, whichever is more likely to result in providing the client with competent service, if it becomes apparent that a client s problems are beyond their competence. Recognize that I do not have the competence to assess and diagnose serious mental illness (such as psychotic symptoms) or offer counselling services to an individual with these presenting concerns. Any service that I provide to address immediate concerns would need to be reflective of my abilities and efforts to maximize benefit/minimize harm until such services are accessed. Due to my concerns regarding possible psychotic symptoms I recognize that I do not have competence to provide services until this has been addressed by a psychiatrist. I believe I should also consider consulting a psychiatrist to determine if there is any service or recommendations they have for the interim basis that would not cause harm to the youth. Value: Risk/Benefit Analysis II.13 Assess the individuals, families, groups, and communities involved in their activities In this situation an assessment to see if there is any potential of imminent harm (to self) given

6 D. Ballance Assignment #2 6 adequately enough to ensure that they will be able to discern what will benefit and not harm the persons involved. II.14 Be sufficiently sensitive to and knowledgeable about individual, group, community, and cultural differences and vulnerabilities to discern what will benefit and not harm persons involved in their activities. the youth s current behaviour is necessary. Consultation with the psychiatrist regarding a risk assessment may assist me in this process. I would also want to consult a professional that has competence in working with aboriginal persons to increase my understanding about cultural differences regarding potential services. Value: Maximize benefit II.18 Provide services that are coordinated over time and with other service providers, in order to avoid duplication or working at cross purposes. I need to ensure services are coordinated between myself and the psychiatrist to meet the needs of the youth through common goals, with clear guidelines of each professional s role/expectations. Value: Minimize harm II.33 Maintain appropriate contact, support, and responsibility for caring until a colleague or other professional begins service, if referring a client to a colleague or other professional. Clearly define my role in the interim period between my referral and psychiatric services, and determine appropriate support (if any) for the care of the youth until the psychiatric evaluation has been completed. I need to consider transition or coordination of services. PRINCIPLE III: INTEGRITY IN RELATIONSHIPS Value: Accuracy/Honesty III.8 Acknowledge the limitations of their own and their colleagues knowledge, methods, findings, interventions, and views. Value: Objectivity/lack of bias III.10 Evaluate how their personal experiences, attitudes, values, social context, individual differences, stresses, and specific training influence their activities and thinking, integrating this awareness into all attempts to I see two issues that I may need consultation/assistance with that are out of my range of competence and knowledge; psychiatric symptoms and evaluation, and understanding cultural differences for coordinating my counselling services for the youth. This requires me to reflect on my personal past experience with clients from an aboriginal culture as well as pre-conceived ideas I might have about how the youth and grandmother should act or make decisions about their

7 D. Ballance Assignment #2 7 be objective and unbiased in their research, service, and other activities. PRINCIPLE IV: RESPONSIBILITY TO SOCIETY services that may be different from my own perspective/culture. Value: Respect for Society IV.15 Acquire adequate knowledge of the culture, social structure, and customs of a community before beginning and major work there. Acknowledge my limited knowledge and experience regarding the aboriginal culture, seek consultation that will help me build my understanding, and integrate these learning s into possible counselling service. Step 3. Consideration of How Personal Biases, Stresses, or Self-Interest Might Influence the Development of or Choice Between Courses of Action My initial reaction to the referral was concern for the youth, and worry that his symptoms might be serious and out of my range of competence. I am concerned that the issues of time, distance, and available funds for a referral for psychiatric evaluation may prohibit the grandmother from consenting and following through with the referral which leaves the youth without adequate care (and a whole other ethical dilemma for me to consider if they refuse consent). My helping instincts lead me to want to provide some type of service on an interim basis, but I need to work through what is in my range of competence and what may be beneficial or harmful as a result of providing some type of immediate care. I am concerned with avoiding negligence in providing care as well as in referring to more qualified professional. I also may be jumping to conclusions regarding the symptoms as being psychotic based on my own culture and beliefs, and recognize the need to consult at some point with a specialist in aboriginal culture to further my knowledge and understanding if these symptoms are actually culture based. I also have some preconceived biases regarding the quality of care in the home based on some stereotypes and brief past experience in working with aboriginal families that I need to modify in how I think about and approach my support to the youth.

8 D. Ballance Assignment #2 8 Step 4. Development of alternative courses of action. My analysis leads me to two courses of action: 1) to make a referral for psychiatric evaluation based on my training and experience and range of competence that do not qualify me to assess psychiatric symptoms/conditions, provide whatever help and support I can to ensure they are able to attend an appointment, and consult with the psychiatrist regarding if/what support I would be able to offer in the interim; or 2) consult with a specialist in aboriginal culture to help determine if the symptoms are culturally based to provide me with more information if a psychiatric referral is appropriate, assess any imminent harm, and provide counseling services to the youth for immediate support. With either option I feel it is also necessary for me to refer the grandmother to a colleague to access support for her in dealing with her own issues (grief/trauma). Step 5. Analysis of Like Short-term, Ongoing and Long-term Risks and Benefits of Each Course of Action on the Individual(s)/group(s) Involved or Likely to Be Affected (e.g., Client, Client s Family or Employees, Employing Institution, Students, Research Participants, Colleagues, the Discipline, Society, Self) Possible Positive Consequences Possible Negative Consequences Alternative 1 Referral to psychiatrist ensures that appropriate professional is completing the evaluation regarding possible psychotic symptoms/condition (addresses the potential greater risk for the youth) Responsibility of care is shared by two professionals that have areas of expertise that provide support to the youth (coordination of services) Consultation regarding possible interim services ensures I stay within my range of The difficulties associated with travelling/waiting for psychiatric assessment may delay appropriate treatment, or difficulties in follow-through for the family Immediate needs may not be addressed and the stress and symptoms for the youth and the grandmother may increase and unhealthy patterns continued (especially if it is determined that I am unable to provide any support) The family may feel like their concerns are not

9 D. Ballance Assignment #2 9 competence It may be determined that I can provide some limited services to help the youth address some immediate issues (through consultation) The grandmother can access professional support for her current issues from a referral to a colleague (in turn my also benefit the youth as he is not the main support system for his grandmother) being addressed and difficulties with trust may arise, or they may have difficulties with the referral itself (view symptoms differently, different priorities, etc.) The grandmother may not follow through on a referral for herself to a colleague for a variety of issues (resistant, doesn t agree, uncomfortable, etc.) Alternative 2 Immediate short-term care is addressed for the youth through counselling (as well as the grandmother through a referral to a colleague) Cultural norms and differences are honoured and taken into full consideration for providing services and deciding if the psychiatric referral is appropriate (possibly an unnecessary referral is avoided) Trust and respect in the counselling relationship will likely be increased through cultural sensitivity and acknowledgement of current needs Follow-up/through will be easier for both the grandmother and youth as they stay in their home community Delay of psychiatric referral may put the youth at greater risk if the symptoms are indicative of psychosis of some form It s possible that any supports/services offered may not be adequate (beneficial) without addressing an underlying serious mental health issue Stress may increase for both the youth and the grandmother (symptoms worsen, support is ineffective) The grandmother may not follow through on her own referral for counselling support A referral for psychiatric evaluation can still be initiated at any point if it appears culture does not explain symptoms Step 6. Choice of Course of Action after Conscientious Application of Existing Principles, Values and Standards I believe that the actions and consequences for the first alternative more clearly support the values in Principle I (Respect for the Dignity of Persons) and Principle II (Responsible

10 D. Ballance Assignment #2 10 Caring) as my greatest responsibility is to the youth as he is in the most vulnerable position. The potential serious nature of his symptoms and the greater risk associated with these symptoms increase his vulnerability. Potential benefit (Principle II) is also possible in alternative 1 as I allow for the provision of some support for the youth I can implement as per the recommendations provided through consultation with a psychiatrist. It would be my responsibility to seek ethical advice and make the psychiatric referral based on my own competencies. Additionally I need to be aware of how my actions may result in benefit or harm. Delaying the referral (as in alternative 2) although it recognizes cultural differences (supports Principle I), may result in harm if symptoms are serious or if my counselling services do not adequately address his needs (if there is an underlying problem). Alternative 2 shows the greatest support for respecting cultural differences in decision making (Principle I & Principle II) and may have potential immediate benefits through counselling efforts through consultation with and expert in aboriginal culture, while recognizing that I would still be considering psychiatric referral. Providing the referral for the grandmother (in both alternatives) allows for her to immediately access support and begin building some skills to support herself and her grandson. Principle III (Integrity in Relationships) is present in both alternatives as I recognize how my background and personal values impact my view of the situation, my competencies, and my current understanding of aboriginal cultures. Additionally, my communication with the grandmother would clearly outline the above and would be a part of informed consent for either alternative. My communication with the youth would be age-appropriate and still maintain honesty and openness.

11 D. Ballance Assignment #2 11 Step 7. Action with a Commitment to Assume Responsibility for the Consequences of the Action I think in this situation, alternative 1 addresses the principles in a more comprehensive way and appropriately deals with the youth s vulnerability and potential risk (primary ethical issue), therefore I believe is the best ethical course of action. I would take steps to assist both the grandmother and the youth in attending the appointment, obtaining informed consent for the referral, and consulting with the psychiatrist to see if it would be appropriate for me to provide some counselling support in the interim. Step 8. Evaluation of the Results of the Course of Action Reflecting on initial feedback from the grandmother while making the referral and obtaining consent would be the first step in evaluating if the action is appropriate. My provision of support in attending the psychiatric evaluation would be a good way of assessing the family s follow-through with the appointment, maintaining contact, building trust, and evaluating how the action is proceeding. If I was providing some interim support (under the supervision of the psychiatrist) I would be able to evaluate the success of the therapy, and meet ongoing needs as necessary. Maintaining and documenting contact with other professionals and the family would be necessary for ongoing evaluation of the situation. Step 9. Assumption of Responsibility for the Consequences of Action, Including Correction of Negative Consequences, If Any, or Re-engaging in the Decision-Making Process if Ethical Issue is Not Resolved If possible I would be able to consult with a specialist in aboriginal culture while waiting for the psychiatric evaluation to confirm whether or not culture plays a role in the youth s symptoms. If it becomes apparent that culture is largely responsible I could reinitiate services with the youth, continue with a more in-depth assessment of the situation, and either

12 D. Ballance Assignment #2 12 delay/reschedule or cancel the psychiatric referral. I could also communicate with the grandmother initially that I would be seeking this consultation if she was resistant to the referral from the outset. If the grandmother refused the referral/action from alternative, I could proceed cautiously with alternative 2. Step 10. Appropriate Action, as Warranted and Feasible, to Prevent Future Occurrences of the Dilemma (e.g., Communication and Problem Solving with Colleagues, Changes in Procedures and Practices) I think I should take steps to build my cultural knowledge of the aboriginal individuals within my community and how their values may affect differences in symptom perception and counselling issues (grief, trauma, loss). I should also continue to build my professional knowledge about appropriate psychiatry referrals and potential services I can provide for this type of client (attend training opportunities, ongoing consultation, etc.). Building a collaborative and consultative relationship with other professionals (aboriginal specialist & psychiatrist) will be important for future situations.

13 D. Ballance Assignment #2 13 Reference Sinclair, C., & Pettifor, J. (Eds.). (2001). Companion manual to the Canadian code of ethics for psychologists (3 rd ed.). Ottawa, ON: Canadian Psychological Association